NCC222819_FRO Submitted_20220809

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department, Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility party will be on record as the party to
accept any Notices of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and
Sedimentation Ordinance. If the financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A c
1. Project where land -disturbing activity is to be undertaken: 9 r
2. Address of land -disturbing activity:
3. Approximate date land -disturbing activity will commence:
Month D y Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.):
5. Approximate acreage of land to be disturbed or uncovered: -2• .2A
6. List total site acreage: *:� . 00
7. Landowners of Record (Use blank page to list a itional owners):
Name: � -f' �o-
Address: 4421 OA r;
Telephone: 0 -rin q 1 q n Fax:
Email Add
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
S ignature:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 3 y /75� Page Book Page
Book Page
Book Page
Ua
Page I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm,{:
Address: dI `l.-� l ern -T),
Telephone:__- t 4
(Area Code)
Email Address: ; &n
t I (Area Code) _ _
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: al'A
Address: *J ,­)f 6&_VbWrA �i,✓p
Telephone: ?o4--22-5377 Fax:
(Area Code)
Emai I Address: t•nMBM ��t�oe Yu�l MQ• .l�f
(Area Code)
0
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual or by an
officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible company or entity, if not an individual.)
Name (
Signature K X \ ^
1, \ G
of LY
certify that
appeared before me this day and :order oath
Witness my hand and notarial e I s
Notary Signature:
My Commission expires:
Title
14,
1 I \-A a Notary Public of the County
State of r�`�T LLn�Q __, hereby
I personally
that this form w executed by hh her.
•
MARIf LYr M
ofa-
NOTARYpUl UA
Mecldenbu U13LIC
� County
North
Carolina
Vision Expires Dec 3
ENGRUMM a PROPEM
MANAGUORf
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax:[phone]
http://landpermits.channeck.org
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